Health, Homelessness, and Conditional Morality in the United States

A homeless man resting on the steps of a building. Source: Jake Stimpson

In 2005, LA Times columnist Steve Lopez met Nathaniel Ayers, a Julliard-educated musician whose diagnosed schizophrenia left him homeless on the streets of Los Angeles. The friendship between the two men grew into a book, as well as the high-profile movie The Soloist. In 2013, with the support of Lopez, a nonprofit organization named Housing Works, and other Los Angeles housing resources, Ayers moved into an apartment with a system of mental health professionals to assist him. His schizophrenia, however, continued to severely inhibit his ability to live on his own. After a conflict with his neighbors, Ayers’ friends, including Steve Lopez, helped him into a mental health institution. The structured care he received at the mental health facility included talk therapy, monitoring, and anti-psychotic medication. Thanks to this care, Ayers still plays the upright bass, violin, cello, and trumpet. Unfortunately, Ayers’ level of care and support lies beyond the reach of hundreds of thousands of people who struggle with both health problems and homelessness. Living without a home often exacerbates mental illnesses, substance use disorders, and other diseases such as tuberculosis and HIV/AIDS. Because health problems can make it difficult to avoid or escape homelessness, homelessness and poor health form a cycle that few can break without external support.

While not all people experiencing homelessness are mentally ill, the factors that cause people to become homeless, such as the inability to pay rent, difficulty finding new housing, or living alone, particularly affect people with mental conditions. The strain of mental illness exacerbates the problems of finding and keeping stable work that pays rent, as well as finding and keeping suitable housing. Many people who suffer from mental illness struggle to find affordable housing that not only provides adequate care for their specific needs, but also does not discriminate against the mentally ill. Without a support network to help with this detailed and difficult search, people with mental illness are at a far greater risk of experiencing homelessness than people without mental illness. According to the 2014 Point-In-Time Count, a biannual nationwide count of those experiencing homelessness, 21% of the 578,000 homeless persons surveyed suffered from a serious mental health condition such as bipolar disorder or schizophrenia. Of those people, 40% lacked any form of shelter. In contrast, only a total of 6% of American adults live with a serious mental health condition.1 According to a study by the National Association of State Mental Health Program Directors, Americans living with serious mental health conditions, with or without housing, die on average 25 years younger than other Americans.2

A homeless woman and her dog sitting on a stool looking desolate. Source: Monica Kelly

Our interactions with people experiencing homelessness often bias our perceptions of mental illness. Oftentimes, we may brush past a homeless individual with a curt nod, or with no acknowledgment at all. Yet, the experience of homelessness itself greatly shapes mental illness, even if a person experiencing homelessness struggled with a mental health condition beforehand. The extreme stress of experiencing homelessness stems from the daily challenge of finding food and shelter while working, looking for jobs, taking care of children, or going to school. Many US cities also criminalize behaviors associated with homelessness, such as sleeping in public places or in cars; thus making survival even more difficult. The sensation of invisibility experienced even in America’s busiest cities also creates severe mental strain. Imagine crying out for help in a crowded room, and watching as everyone around you ignores your pain. From a neurological perspective, this stress alone can damage neurogenesis and create a feedback loop that increases one’s vulnerability to mental illness. Stress elevates glucocorticoid levels, which regulates white matter in the brain. White matter changes have been linked to schizophrenia, bipolar disorder, and PTSD, among other serious mental health conditions. Homelessness itself can act as a traumatic event, which further perpetuates this brain chemistry spiral.

Many people experiencing homelessness also lack access to adequate health services. Utilizing a clinic or health care center, even one specifically designed to serve people experiencing homelessness, becomes exponentially more difficult. While Federally Qualified Health Centers and Health Care for the Homeless Clinics provide crucial, basic health care for free, treating serious mental health conditions over time often requires health insurance.3 Even with Medicare and Medicaid, which cover over 27% of all mental health care in the US,4 parity in mental health insurance varies greatly depending on the state. Most insurance plans do not cover mental illnesses to the same extent as physical illnesses, in part because mental health treatment can be prohibitively expensive. Those without insurance do not have access to early visits or screenings, check-ups, or prescriptions. As a result, health conditions often worsen until they require hospitalization, which is one of the most expensive treatment options for individuals and for the US health system.

Another common negative cultural association of Americans is the belief that people experiencing homelessness abuse alcohol and/or illicit drugs. Indeed, in the 2014 Point-In-Time Count, 20% of the surveyed people experiencing homelessness suffered from a chronic substance use disorder; 40% of that population, moreover, lived without any kind of shelter.1 These numbers correlate closely with the count of those suffering from mental health conditions on the street. Together, people with mental illness and with substance use disorders make up more than 40% of all persons experiencing homelessness in America, a total of over 240,000 people,5 even without looking at the overlap between these groups, chronic homelessness, and veteran homelessness. Homelessness and substance abuse disorders can create a self-reinforcing cycle similar to that of mental illness, albeit with several distinctions. Testable disqualification for various housing programs due to the illegality of many drugs and the instability of their users creates an additional problem for addicts, especially with the ease of modern drug testing. Many shelters, buildings, programs, and jobs require sobriety as a prerequisite for consideration. High arrest rates and mandatory sentences for the use of drugs like cocaine further compound this problem. Once he or she has a felony record, a person experiencing homelessness will find it nearly impossible to find good, affordable housing with supportive services. While civil rights laws that govern housing require an individualized assessment of each housing applicant, these assessments often require the applicant to first enroll in a recovery program, even though quality rehabilitation is very expensive.6 The application decision rests solely on the housing provider or landlord. As a result, people with mental illness, substance use disorders, or criminal records often cannot attain suitable accommodation. The current “three-quarter housing” problem in New York City represents one result of the national housing crisis – people struggling with addiction or mental illness cram into “sober,” or “transitional,” homes, which in reality are unregulated housing where stability and constancy depends entirely on the decision of the landlord. New York City Mayor Bill de Blasio recently criticized landlords for “exploiting addicts and homeless people by taking kickbacks on Medicaid fees for drug treatment while forcing them to live in squalid, illegal conditions.”7

Even Public Housing Agencies (PHA) such as Section 8, a low-income voucher-based housing program, or public housing apartments, will not accept applicants unless their criminal conviction occurred “a reasonable time” in the past.8 Any “drug-related criminal activity” can also mean immediate disqualification from PHA. These policies affect whole families by evicting those who have been convicted of a drug-related crime. Traditional services like halfway houses, which work to support people with a history of mental illness, substance abuse disorders, or criminal convictions, can effectively transition those in their care to permanent housing and help sustain that permanent change. If such a transition fails, then those who need long-term support are left at great risk. The lack of permanent supportive housing that provides rehabilitative, health, and job-related services creates an environment in which people with substance abuse disorders must stop using any drugs order to receive help, sometimes an unachievable request for those who have been struggling with their disorder for years.

A young boy and his dog sleeping on the side of the street. Source: Transformer18

People experiencing homelessness are also more susceptible to a variety of ailments, such as tuberculosis (TB), virulent influenza, pneumonia, and illnesses related to poor hygiene.9 High rates of HIV/AIDS also persist among people experiencing homelessness, especially in conjunction with substance abuse and intravenous drug use. These health problems stem from environmental exposure, lack of access to safe water and sanitation, and sexual violence.9 The latter particularly affects women living on their own or with dependents. Living without a guarantee of personal safety, whether on the street, in shelters, or in precarious living situations, creates vulnerability to sexual violence from acquaintances, strangers, sex traffickers, or intimate partners. The fact that people experiencing homelessness often avoid the police also increases their risk of being victims of violence. Low vaccination rates related to poor health coverage also contribute to the prevalence of health conditions otherwise uncommon in the United States.9 Illnesses such as pneumonia and TB often spread in high-density shelters or shared apartments. Poor bedding, limited access to washing machines, and a lack of clean clothing can cause scabies and infectious diseases such as Bartonella quintana, the pathogenthat caused trench fever during World War I.10 Health care and hospitalization do not suffice to permanently treat illnesses so closely tied to living conditions, especially since illnesses such as HIV/AIDS require extensive treatment and an elaborate prescription regimen that must be rigorously maintained. This treatment is not accessible or feasible without health insurance and daily stability.

An overarching problem with the intersection of homelessness and public health is the sense of moral judgment with which our society views mental illness, substance use, sexually or intravenously transmitted diseases, poor hygiene, and homelessness itself. The unacceptable living conditions of people experiencing homelessness repel society at large, which often leave the people who dwell in these conditions ignored. Through requirements of sobriety, discrimination towards the mentally ill, refusal to accommodate convicted offenders, low employment rates among populations vulnerable to homelessness, and rejection of those with different lifestyles, it is virtually impossible to recover from homelessness or poor health conditions without money and support, neither of which American society provides adequately. Poor health and poverty are not moral failings, and housing should not be conditional. Housing should take priority, without any prerequisites. If someone’s health condition causes her to lose the roof above her head, her support should not disappear. We need a comprehensive system of Permanent Supportive Housing, a movement that integrates systems of treatment into housing so that people can experience a combination of stability, sanitation, education services, job services, and health services. Lasting change for more than half a million homeless Americans comes from improving health care and ending homelessness.

Erika Lynn-Green is a sophomore in Calhoun College. Erika is an English major from California. She can be contacted at erika.lynn-green@yale.edu.__________